OBSTETRIC IN NURSING

THE MENSTRUAL CYCLE

• Cyclic endometrial bleeding in response to hormonal changes

• NORMAL MENSTRUAL CYCLE
o Having a cycle anywhere from 24 – 38 days. Common at 28 days
o Bleeding anywhere from 4th – 7th day. Common at 5 days
o Losing 5 – 80 mL over the course of menstrual period
▪ 50 – 60 mL, 30 – 60 mL or ¼ of a cup
o Bleeding → Thickening → Preparation for Implantation → Vasoconstriction
• What to Report?
1. No Menstrual for more than 3 months
a. Common cause of amenorrhea (absence of menstruation) is pregnancy
2. Getting a Fever
a. May be caused by infection
3. Heavy Bleeding (Menorrhagia)
a. More than 80 mL / More than 7 days / Changing napkins every less than 2 hours.
b. Excessive bleeding may lead to Iron Deficiency Anemia.
c. NOTE: Women of Reproductive age (Increase Iron for 15 mg/day)
4. If you are having severe pain during menses.
a. Most common cause: Endometriosis (secondary to Dysmenorrhea)
5. A change from regular to irregular cycle.
• Body Parts Involved
1. Uterus
a. Hormone Involved: None
2. Hypothalamus
a. Hormone Involved: GnRH (Gonadotropin Releasing Hormone)
3. Anterior Pituitary Gland
a. Hormone Involved: Follicle-Stimulating Hormone
i. Hormones of maturation of ovum
ii. Stimulates ovary to produces Estrogen
iii. Primary Follicle → carries Immature Ovum
iv. Graafian Follicle → carries Mature Ovum
1. One Follicle every month/cycle
2. First ovarian hormone is Estrogen
b. Hormone Involved: Luteinizing Hormone
i. Responsible for Ovulation
ii. Stimulates Ovary to produces Progesterone
iii. Ovulation: Release of Mature Ovum (Function of Luteinizing Hormone)
1. During Maturation → Decease in Progesterone, Increase in Estrogen
2. During Ovulation → Decrease in Estrogen, Increase in Progesterone
3. Prior Ovulation → Decrease in Progesterone, Increase in Estrogen
4. During Ovulation there is a sudden Increase in Progesterone
• In a 28-day cycle, when do you expect ovulation to occur → DAY 14
• In a 32-day cycle, when do you expect ovulation to occur → DAY 18
o For Irregular Menstruation always subtract to 14
o Fertile Characteristics → thin, watery, clear, alkaline, wet, slippery, abundant, (+) ferning (fern-like lines in the microscope),
(+) SpinnBarkeit (stretchy)
o Use of SpinnBarkeit/Billing’s Method
▪ Abstain from sex if cervical mucus is fertile until 4 days after the last episode of fertile mucus.
o Ovum survives for 24 - 48 hours
o Sperms survives for 48 – 78 hours
▪ Minimum sperm count: 20 million/mL
• For Irregular Cycle
o Culprit: FSH
o If there is a delay in maturation, there is a delay in ovulation
1. Chart the shortest and longest cycles for the past 6 – 8 consecutive months
2. Determine the shortest cycle and then subtract in 18 days (constant).
3. Determine the longest cycle and then subtract in 11 days (constant).
4. The result will be the fertile days.
a. Example:
 Shortest = 24 Longest = 32

24 32
− 18 − 11
6 21
Days 6 to 21 is the FERTILE DAYS (8 – 19 days fertile duration)
Day 22 to Day 5 of the next cycle is the INFERTILE DAYS
4. Ovaries
a. Almond-shaped female sex glands for production of Estrogen and Progesterone
b. The Cortex of the Ovary contains the developing follicle.
i. The early the Menarche (1st menstruation), the early the menopause can occur.
ii. Menstrual Cycle = 400 cycle in Whole Life
5. Estrogen
a. Development of secondary sexual characteristics = PRIMARY FUNCTION
i. T → Thelarche (Breast Development)
ii. A → Adrenarche (Axillary Hair)
iii. M → Menarche (1st menstruation) – 12 – 13 years old or 17 years old (late)
iv. A → Adrenarche (Pubic hair)
b. Fat distribution in the hips and legs
c. Inhibits FSH → Increase in Estrogen = No FSH
d. Responsible for Ductile Structures of the breast
e. Estrogen is the hormone responsible for growth of long bones and early closure of epiphysis (pineal) of the long
bone. NOTE: Growth stops at 16 – 18 years old (female)
f. Responsible for increased sexual desires and increased in vaginal lubrication
g. Responsible for fertile cervical mucus
6. Progesterone
a. Prepares endometrium for implantation.
b. Increase Basal Body Temperature (increase by 0.3 – 0.6 C)
c. Inhibits LH → Increase in Progesterone = No LH
d. Responsible for mammary gland development
e. Mood Swings (after ovulation)
f. Muscle Relaxant (Decreases peristalsis)
g. Responsible for infertile cervical mucus
i. Characteristics of Infertile Cervical Mucus
1. Thick, sticky, dry, dense, opaque, (-) ferning, (-) SpinnBarkeit (not stretchy)
ii. Abstain from sex if Basal Body Temperature (BBT) is increased for 3 – 4 days
iii. SYMPOTHERMAL → Billing’s Method + BBT

THE OVARIAN CYCLE

• Hormone production, maturation of ovum and ovulation

1. FOLLICULAR PHASE
a. Occurs 1 – 14 days or 1 – 13 days
b. FSH is responsible for maturation of ovum and production of Estrogen (increase)
2. UTERINE CYCLE
a. Endometrial changes are controlled by the ovarian cycle.
i. MENTSTRUAL = Bleeding (1 – 6 days)
1. Decrease in Estrogen and Progesterone = Endometrium is Thin
ii. PROLIFERATIVE = Thickening (7 – 14 days or 7 – 13 days)
1. Increase in Estrogen, post-menstruation, pre-ovulation, Estrogenic
3. LUTEAL PHASE
a. LH is responsible for Increase in Estrogen, Ovulation, and After Ovulation.
b. Corpus Luteum → Ruptured Graafian Follicle under the influence of LH (color yellow)
c. Increase in Progesterone
4. SECRETORY PHASE
a. Twisted and spongy = in preparation of implantation.
b. AKA Progestational, Post-ovulation, Pre-Menstruation
c. Increase in Progesterone, Decrease in Estrogen
d. NOTE: If there is Implantation (in the Uterus = Upper most/Fundus), HCG Production (1 st hormone to be produced after
implantation) → Maintain the life of corpus luteum in the ovary for 1st 2 months → Source of Estrogen and
Progesterone for the 1st 2 months, Progesterone maintains the endometrium → No Menstruation → Amenorrhea →
Pregnancy.
 i. Decrease Progesterone = Increase/High Chance of Abortion
ii. 3rd Month Placenta is complete
iii. No Ovulation = No fertilization = No HCG production
5. ISCHEMIC PHASE – vasoconstriction (Day 27-28)
a. Corpus Albicans → Decrease in Estrogen and Progesterone → In preparation for menstruation

RELATED TERMINOLOGIES

1. Menarche → First Menstruation (12 – 13 years old or 17 years old)

2. Dysmenorrhea → Painful menses
3. Amenorrhea → absences of menstruation
a. Primary → menses have never occurred (17 years old menarche)
b. Secondary → previously menstrual bleeding has occurred
c. Regular Cycle = in 3 missed periods
d. Irregular Cycle = in 6 missed periods
e. NOTE: Do not recommend pills if not menstruating for 2 years.
4. Menorrhagia → “Breakthrough”
a. Bleeding in between menses/bleeding at irregular intervals.
b. Common at: IUD, Depo Provera (hormonal medication of the progestin type, it suppresses the ovulation and keeping your
ovaries from releasing an egg), Implanon, Pills
5. Menorrhagia → “Excessive”
a. Losing more than 80 mL or more in each period.
b. Bleeding that lasts more than 7 days.
6. Menopause
a. Cessation of menses. Average of 51 years old

FERTILIZATION

• Union of Ovum and Sperm = Zygote

• AKA Conception / Fecundation
• Fertilization would result to 22 pairs of autosomes and 1 pair of sex chromosomes
• Y = Female, X = Male
• Site: Ampulla of the Fallopian Tube (Outer Third)

DYZYGOTIC TWINS

• 2 Ovum fertilization by 2 sperm

• Multiple ovulation
• Under ovulatory drug (clomid)
• Maybe same or different sex
• 2 bags of water, 2 placentas

MONOZYGOTIC TWINS

• One zygote and splits into 2 identical same sex

• Common
• Types:
1. Dichorionic Diamniotic = 33%
a. Splitting at 1st 3 days
b. 2 placenta, 2 Bags of Water (BOW)
2. Monochorionic Diamniotic = 66%
a. Splitting at 4 – 7th day
b. 1 placenta, 2 Bags of Water
3. Monochorionic Monoamniotic = 3%
a. Splits at 8th – 13th day
b. 1 placenta, 1 Bag of Water
4. Conjoined Twins
a. Splitting More than 13th day
b. Cleavage is incomplete

COMPLICATION OF MULTIFETAL GESTATION

1. Pre-eclampsia
2. Polyhydramnios → excess amniotic fluid
3. Overdistention of Uterus
 4. Post-partum Hemorrhage
5. Malpresentation
6. Cord Prolapse
7. Dystocia → Difficult labor *Multifactorial
8. Prematurity and Low Birth Weight (LBW) → Less than 2500 grams Birth Weight
a. Very Low Birth Weight (VLBW) → Less than 1500 grams Birth Weight
b. Prematurity → Less than 37 weeks
9. Placenta Previa → Placenta at near or over cervical opening
10. Structural Deformities

FETAL GROWTH AND DEVELOPMENT

• Zygote Stage (Fertilization – 2 weeks)

o Cleavage (2-cells)
o Blastomeres (4-cells / 8-cells) → after 3 – 4 days
o Morula (16 – 50 cells) → after 3 – 4 days
o Blastocysts (Reorganized Morula) → Implantation/Nidation
▪ IMPLANTATION
• Signs of Implantation:
o Vaginal Spotting and slight pain
• Site: Posterior Fundus
• When: 7 – 10 days after fertilization/6-8 days
▪ BLASTOCYSTS
1. Trophoblasts (Covering)
a. Brushing of the Endometrium
i. After Implantation
1. Chorion
a. Chorionic Villi + Decidua Basalis (Pregnant Endometrium) = Placenta
2. Inner Cell Mass
a. After Implantation

Embryo Amnion

Fetus Cord Bag of Water

• SIDE KNOWLEDGE
o If the Decidua Formation is Deficient, may lead to abortion and Placenta Accreta
(Abortion Implantation) → Increta (Myometrium) and Percreta (Perimetrium)
o Normal: Placenta planted in Endometrium
o The more the delay of placenta delivery, the more bleeding
• Embryonic Stage (2 – 8 weeks) (Organogenesis Period) *MOST CRITICAL
• Fetal Stage (8th weeks - Term)

THE GROWING FETUS

• Month 1 (1 – 4 weeks)
o All system in the rudimentary form (one tube)
o Heart chambers formed. Heart Beating (as early as 14 days)
o Beginning formation of eyes, ears, and nose
o With arms and legs buds.
o By the end of the first month, the fetus is about 1 cm long and weights 400 mg
o NOTE: Heart is the first function organ, not audible yet. (2 weeks or 14 days)
• Month 2 (5 – 8 weeks)
o Head is enlarged in proportions the rest of the body (cephalocaudal approach)
o Rapid Brain Development
o The Neural Tube (Brain, spinal cord, and other neural tissues in the CNS is well formed)
o SIDE KNOWLEDGE:
▪ Intake of Folid Acid (Vitamin B9) in First Trimester
• Dose: 400 mcg/day = if no history of Neural Tube Defects (NTD)
o 40 mg/day = if with history of Neural Tube Defects (NTD)
▪ Alpha-fetoprotein (AFP) is manufactured by fetal liver present at 15 weeks.
• AFP → through Amniocentesis (15 – 20 weeks)
o High AFP → Neural Tube Defects
o Low AFP → Down Syndrome
 o AFP testing after 20 weeks will lead to FALSE HIGH AFP
o All Neural Tube Defects cases must be delivered via CS not NSD
o External Genitalia Formed
o Sonogram shows a gestational sac
o Diagnostic Procedure (6th weeks)
o By the end of the 8th week, organogenesis is complete
o By the end of the 2nd month, the fetus is about one-inch (2.5 cm) and weighs 20 g
• Month 3 (9 – 12 weeks)
o Placenta is complete
o FHT is audible by Electronic Doppler
▪ Electronic Doppler → as early as 8th week but clearer/louder at 10 – 12 weeks
o Sex is distinguishable by appearance
o Fetus begins to swallow (Amniotic Fluid)
o Kidneys begins to excrete urine
o Liver produces Bile
o Circulatory system is working
o The arms, hands, fingers, and feet, toes are fully formed
o All organs and limbs are present
o By the end of the 3rd month, fetus is about 4 inches long and weighs 45 grams.
• Month 4 (13 – 16 weeks)
o Quickening → First fetal movement felt by multigravida
o Formed eyes, ears, and nose
o Scalp development at birth, abundant = post-term
o Fetal Heart Rate via Fetoscope
o Lanugo begins to appear, fine downy hair for warmth and skin protection
o By the end of the 4th month, the fetus is about 6 inches long (9 cm) and weighs 55 – 120 grams.
▪ Meconium in bowels, intestinal secretions → green color, thick = 1st poop
▪ NOTES ON MECONIUM
• Meconium staining is a sign of fetal distress except for Breech Presentation
• Meconium Staining → most common post-term (mostly)
• Post-term (4 weeks and above) suffered placental insufficiency → Fetal Hypoxia → Vagal Reflex
Stimulation → relaxation of anal sphincter and increase peristalsis → Meconium Staining → Green
Skinned Newborn
• Month 5 (17 – 20 weeks)
o Lanugo completely appears
o Quickening → felt by primigravida
o FHT by ordinary Stethoscope
o Nipples appears over the mammary gland
o Fetus actively swallow amniotic fluid (600 mL/day)
o Age of Viability (Survival is Possible)
o End of the 5th month, fetus is 25 cm (10 inches) and weighs 435 – 465 g
• Month 6 (21 – 24 weeks)
o Body is well proportioned
o Skin is red and wrinkled
o Eyebrows and eyelashes are well defined
o The skin is covered with vernix caseosa → white, cheese substance for thermoregulation and skin lubrication
o Hearing is established
o By the end of the 6th month, fetus is 28 – 36 cm (11– 14 inches) long and weighs 780 g
o NOTE: Preterm has more Vernix Caseosa and Lanugo
• Month 7 (25 – 28 weeks)
o Surfactant can be demonstrated in the amniotic fluid.
o Hearing fully developed
o Body less wrinkled
o Testes begins to descend in the scrotal sacs
o The blood vessels of the retina are thin.
o Fluid in the Fetal Lungs for Lung Expansion → alveolar development to prevent Pulmonary Hypoplasia
▪ Oxygen toxicity can lead to neonatal blindness
o By the end of the 8th month, the fetus is 35 – 38 cm (14 – 15 inches) and weighs 1200 grams.
o Daily counting of fetal movement increases between 28 – 38 weeks
o NOTE: In Women with a multifetal gestation, daily fetal movement are significantly increased.
o NORMAL FETAL MOVEMENT COUNT: 10 – 12 Fetal Movements in 1 hour
 o Ways to Stimulate Fetal Movement:
▪ Eat
▪ Move
▪ Sounds
▪ Massage
o BEST POSITION OF THE MOTHER: Left/Reclining
o BEST TIME OF THE DAY: Daytime hours
▪ Less than 10 in 1 hour = Extend/hr
▪ Less than 10 in 2 hours = Report
• Month 8 (29 - 32 weeks)
o Subcutaneous fat begins to be deposited, Iron deposits, calcium deposits.
o Skin is smooth and pink
o Fingernails grow
▪ Brown fats = Heat Insulator
▪ Focus of Growth:
• 1st Trimester (1 – 3 months) → Organogenesis
• 2nd Trimester (4 – 6 months) → Fetal Length
• 3rd Trimester (6 – 9 months) → Fetal Weight Gain
o Birth position assumes. BEST FETAL POSITION: Left Occiput Anterior (LOA) 2nd Position: Right Occiput Anterior (ROA)
o CNS has matured enough (29 – 32 weeks)
o Active more reflex is present.
o By the end of the 8th month, the fetus is in 38 cm (15.2 inches) and weighs 1600 grams
o Moro Reflex AKA Startle reflex
▪ Leopold’s Maneuver = 8th month and above
• Leopold’s Maneuver helps to determine the fetal presentation
• Month 9 (33 – 36 weeks)
o Nails are firm = term, soft = preterm, long = post term
o With definite wake and sleep pattern
o Lanugo disappearing
o Most babies turn into vertex position (most common)
Longitudinal = 99% 95% → Cephalic
NSD
o Fetal Lie 4% → Breech
Transverse = 1% → Shoulder Press – CS
o External Version → Abdominal manipulation to change the presentation
o Term/Consent/Floating
▪ Lecithin (Abundant) and Sphingomyelin Ratio
• L/S is 2:1 = 35 weeks (Mature Lungs)
▪ Presence of Phosphatidyl Glycerol (PG) (Surfactant) confirms the lung maturity (36 weeks)
o By the end of the 9th month, the fetus is 42 – 48 cm (17 – 19 inches) and weighs 1800 – 2700 grams
o At 30 weeks, the mother is rushed to the hospital complaining of contractions. Upon Assessments, Bag of Water is intact,
FHR is 146, cervix dilated, V/S is stable. The Doctor will give:
▪ Tocolytic Agent = Muscle Relaxant, to stop contractions, Management for Preterm labor
• Its → Indomethacin
• Not → Nifedipine (Procardia)
• Yet → Yutopar (Ritodrine) TOCOLYTICS
• My → Magnesium Sulfate
• Time → Terbutaline (Brethine)
▪ Contraindication of Tocolytics:
• Cervical Dilation: More Than 3 cm
• Significant Vaginal Bleeding
• PROM → Premature Rupture of the Membrane
• Maternal Tachycardia or Cardiac Disease
• Fetal Distress
• Chorioamnionitis
▪ Antenatal Corticosteroid:
• Betamethasone → 12 mg via IM every 24 hours for 2 doses
• Dexamethasone → 6 mg via IM every 12 hours for 4 doses
• Month 10 (37 – 40 weeks)
o Little Lanugo
o Testes have descended
o With good muscle tone and reflexes
 o Fetus kicks actively (felt in the upper abdomen)
o Fingernails extended over the fingertips
▪ Preterm has underdeveloped muscle
• Partial Reflex
• Lack of Reflexes
o Creases on the soles of the feet cover at least two thirds of the surface = Term
▪ Smooth soles = Preterm
▪ Deep Creases = Post Term
o Lightening occurs two weeks before labor → Primigravida
▪ Settings of Presenting Part
▪ In Multigravida: 1 day before the labor
o By the end of the 10th month, the fetus is 48 – 52 cm (19 – 21 inches) long and weighs 3000 grams

PHYSIOLOGIC CHANGES (CERVIX)

DURING PREGNANCY

• Goodell’s Sign → Increase in Estrogen Cervix becomes Edematous (Softening of the Cervix)
• Operculum → Mucus plug
o Seal of the uterus
o Has Bacteriostatic Effects → prevents the growth of bacteria
o Increase in Estrogen → Hyperplasia to the mucosal gland
o Increase of production of mucus → accumulation of mucus

PRIOR PREGNANCY

• Ripening of the Cervix → if “Buttersoft” → cervix is ready to dilate

DURING PREGNANCY

• Dilatation →Internal Examination (IE)/Manual Manipulation → 10 cm = Fully Dilate (IE=every 4 hours)

o Primi: 1cm/hr
o Multi: 1.5 cm/hr
o Full bladder → instruct the mother to void every 2 – 3 hours
• Effacement
o Thinning of the Cervix
o Internal Examination, %
▪ 2 cm = 0%
▪ 1 cm = 50%
▪ 0 cm = 100%

AFTER PREGNANCY

• Internal OS closes 1 week after the delivery

• External OS becomes wider
o From circular to transverse.
• LOCHIA → A vaginal discharge after giving birth. (Postpartum Bleeding)
o Rubra → Dark Red → lasts 3 – 4 days
o Serosa → Pinkish Brown → lasts 4 – 10 days
o Alba → Whitish Yellow → lasts 10 – 28 days
o Note for Odor and Duration

HAASE’S RULE

• Estimated Fetal Length (EFL) in cm

• First 5 months =(𝑚𝑜𝑛𝑡ℎ)2
• 6th to 10th Lunar Month = Months x 6

AMNIOTIC FLUID, BAG OF WATER, AMNIOTIC SAC

• The major source of amniotic fluid after 20 weeks is the Fetal Kidney (Fetal Urine)
• Normal Value: 500 – 1000 mL or 700 – 1000 mL or 800 – 1200 mL (500 – 1200 mL) = Ultrasounds
• pH of Amniotic Fluid = 7 – 7.25
• Normal Color: Clear
• NITRAZINE PAPER TEST (pH Paper) → Blue/Green = Alkaline = Check FHR
 o Priority of Nurse if Bag of Water (BOW) Ruptures → Check FHR
o Best position for Cord Compression:
▪ Trendelenburg
▪ Knee-chest
▪ Hip Evaluation
▪ All-fours position
o If the Cord Protrudes = cover using moist gauze to prevent drying → can lead to atrophy of umbilical vessels

FUNCTION OF AMNIOTIC FLUID

1. Protection from trauma → MAJOR FUNCTION

2. Maintain Temperature
3. Prevent cord compression
4. Helps in delivery
5. For Musculoskeletal development
a. NOTES:
i. Less than 500 mL = Oligohydramnios
1. Indication: Fetal Kidney Malfunction or Renal Agenesis
2. Risk Factors: Pulmonary Hypoplasia, Fetal Injury
ii. More than 1500 mL = Polyhydramnios
1. Indications: GI Obstruction, Swallowing Problem, Diabetes → Macrosomia → Fetal Polyuria
a. Esophageal Atresia and Tracheoesophageal Fistula
i. Type A → Isolated Esophageal Atresia
ii. Type B → Proximal Fistula with Distal Atresia
iii. Type C → Proximal Atresia with Distal Fistula
iv. Type D → Double Fistula with Intervening Atresia
v. Type E → Isolated Fistula
b. Duodenal Atresia – Malformation of the Duodenum resulting in complete bowel obstruction
i. Type I → Duodenal Web → a thin membrane of mucosa blocks the duodenum.
ii. Type II → Fibrous Cord → the duodenum ends are separated but attached by a
cord.
iii. Type III → Atretic Gap → Complete Interruption. The duodenum ends are
separated, but there’s no tissue between them.
2. Diabetes → Macrosomia → Fetal Polyuria
a. Indications: Multiple Pregnancy
b. At risk for: Preterm labor, Abruptio Placenta
i. Preterm is also at risk for Breech Presentation

ABNORMAL COLORS OF AMNIOTIC FLUID

• Green = Meconium Staining

• Golden Yellow = Hemolytic Disease of the Fetus = Erythroblastosis Fetalis

Bilirubin

Related to Rh Incompatibility, Mother is Rh- (No D-Immunoglobulin), Fetus is Rh+ (with Anti-D)

RhoGAM

• RhoGam
o Prevents antibody formation (prevention)
o Anti-D Immunoglobulin
o Given to prevent further problem to protect next pregnancy
o 95% of Filipinos are Rh+
• Indirect Coombs Test
o Positive Result → With antibody formation
o Negative Result → No antibody formation = GIVE RHOGAM

UMBILICAL CORD/FUNIS

• Color: Grayish white. NO NERVE SUPPLY

• Average length: 50 – 55 cm
• Less than 35 cm (short) = at risk for Abruptio Placenta
• More than 70 cm (long) = at risk for Cord Prolapse
 • Artery = 2 → Deoxygenated
• Veins = 1 → Oxygenated
• Wharton’s Jelly → to protect vessels from rupture
o Best time to cut umbilical cord = when pulsating stops
• Ductus Venosus → connects umbilical vein to inferior vena cava. BYPASS LIVER
• Foramen Ovale → opening between the 2 aortas
• Ductus Arteriosus → connects pulmonary artery to descending aorta. BYPASS LUNGS
• NOTE: In fetal circulation, the placenta provides the oxygen for the baby not the fetal lungs
o Fetal RBCs = Increase
o Fetal Oxygen Blood = 70%
▪ Deoxygenated Blood = 30%

FETAL CIRCULATION

1. Oxygenated blood from placenta → Umbilical Vein (1)

Ductus Venous

Inferior Vena Cava

Right Atrium

Foramen Ovale

Left Atrium

Left Ventricle

Higher Oxygen demand on the Ascending Aorta

upper part than the lower part
Upper and Lower parts of the body

2. Blood returning to the heart (Carbon Dioxide + Waste Products

Right Atrium

Right Ventricle

Pulmonary Artery

Ductus Arteriosus

Descending Aorta

Umbilical Arteries

Placenta

a. In fetal circulation, Right side is stronger than the left side of the heart
b. Failure of Foramen Ovale to close is Defect (Atrial Septal Defect AKA Acyanotic Heart Defect) = Left to Right Shifting
c. Prostaglandin E Inhibitor → closes ductus arteriosus
d. To close the Ductus Arteriosus, the fetus needs to vigorously cry
PLACENTA

• Attaches to the uterine wall and allows metabolic exchange between fetus and the mother.
• Placenta expands on the first 5 months
• A normal placenta is round, or oval-shaped and about 22 cm in diameter. It is 2 – 2.5 cm thick
• Placenta weighs up to 500 – 600 grams at term
• 2 sides:
o Schultz → smooth and shiny (baby side)
o Duncan → rough and dry
▪ Cotyledons → 15 – 20

FUNCTION OF PLACENTA

• Exchange of Oxygen and Carbon Dioxide

• Transport nutrients
• Waste Excretion
• Fetoplacental circulation
• Production of Hormones
• Serves as protective barrier to some microorganism
o TORCH
o T – Toxoplasmosis
o O – Other Infections
o R – Rubella (Germa Measles)
o C – Cytomegaly Virus
o H – Herpes Simplex Virus
▪ Toxoplasmosis → High risk for transmission after 28 weeks
• No cats, raw meat/Undercooked
• Continue taking ARV (Zidovudine)
o Anti-retroviral
o Reduces the risk of transmission from 95% to 2%
▪ Syphilis
• After 16 weeks (crosses the placenta)
o Provide early treatment (Penicillin IM or Erythromycin)
• NOTE: Purpose of Eye/Crede’s Prophylaxis → to precent gonorrhea and/or chlamydia

PLACENTAL HORMONE

• HCG → Human Chorionic Gonadotropin

o Appears in maternal serum as early as 24 – 48 hours after implantation
o Gradually increase until around 10 weeks 60,000 to 140,000
• Function of HCG
1. Prolongs the life of corpus luteum for the 1st 6 – 8 weeks (1st 10 weeks/1st Trimester)
2. Basis for pregnancy: Probable Sign
*False Positive Result → Urine
a. Taking contraceptives pills
b. Women who have proteinuria
c. HEALTH EDUCATION:
i. Limit Fluid intake the night before the test to concentrate the urine
ii. 1st voided urine (most concentrated urine)

HUMAN PLACENTAL LACTOGEN (HPL)

• Another term for Human Chorionic Somatomammotropin

• Produce as early as 6 weeks. At peak after 20 weeks
• Function and Effects:
o Insulin-Antagonistic Hormone (Major)
o Lactogenic Properties (lactation preparation)
▪ Effects: The Diabetogenic effect of pregnancy
▪ Note: All placental hormone increases insulin resistance
▪ All pregnant: Screening for Gestational Diabetes Mellitus (GDM) on between 24 – 28 weeks
• Increase in HPL after 20 weeks
ESTROGEN

• AKA Estriol → Placental Estrogen

• Expansion of Blood to meet fetal needs.
• Vascularization = Increase in blood supply
o Vascularization → Vasocongestion → Bluish in color
o Chadwick’s Sign → Bluish discoloration of vagina
▪ Happens when there is increase in Estrogen → Expansion of Blood → Increase in Vascularization →
Vasocongestion → Bluish/Purplish Discoloration
o Nasal Congestion
o Softening of Gums
o Palmar Erythema
• Secretions (Under Estrogen)
o L – Leukorrhea → whitish vaginal discharge (odorless)
▪ Caused by increase estrogen → increase WBC Count → Whitish Vaginal Discharge
o E – Excessive Salivation (Ptyalism) = drooling
o O – Operculum (Cervical Mucus Plug)
▪ + bacteriostatic effect = X Vaginal Douching
o Softening of the Cervix → Goodell’s Sign
o Softening of the Lower Uterine Segment → Hegar’s Sign
o Ascending Infection = Common cause of Premature Rupture of the Membrane (PROM)

o MOST CONTRACTILE PORTION OF THE UTERUS DURING LABOR IS FUNDUS (UPPER UTERINE SEGMENT =
THICKER)
o NON-CONTRACTILE PORTION OF THE UTERUS DURING LABOR IS LOWER UTERINE SEGMENT = THINNER
o DURING LABOR, CERVIX DILATES

TYPES OF CESAREAN (CS)

1. Classical CS
a. Fundal incision
b. X Vaginal Birth After Cesarean (VBAC)
c. Shorter to perform, difficult to repair, heals slower, more blood loss, more GI complication, more postpartal infections
2. Transverse/Bikini CS
a. Lower Uterine Segment Incision (Uterine Segment/Isthmus)
b. √ Vaginal Birth After Cesarean (VBAC) → after 2 years
c. Longer to perform, easier to repair, heals faster (transverse), less blood loss, less GI complication, less postpartal infections
3. NOTE: CS = Maximum of 3

ENLARGEMENT OF THE UTERUS

• Hypertrophy to myometrium (muscular layer)

• Non-pregnant Weight: 50 – 60 grams
• Non-pregnant Shape: Inverted Avocado
• Pregnant Weight: 1000 – 1100 kg containing a maximum of 5 kgs
• Pregnant Shape: Ovoid Shape
o Estrogen and Progesterone Level during pregnancy
1st Trimester
2nd Trimester
3rd Trimester = gradually/slowly decreases in preparation for labor
E P
o After delivery, in 6 weeks = uterus has returned to non-pregnant state (70 – 80 grams = weight of uterus) (from 50 – 60 g)
o IUD is not allowed to Nulligravida because of size of uterus, it can damage uterus because of IUD procedure.

PROGESTERONE

• Functions:
o Muscle Relaxant
o Decrease Peristalsis (Hypotonic GI tract)
o Maintains endometrial lining
o Fluid retaining hormone → weight gain
o Increase Basal Body Temperature → Progesterone has thermogenic action
o Mammary gland development for lactation
▪ Prior to labor, Decrease Progesterone → Fluid not retaining → weight loss
 ▪ Colostrum has laxative effect

ANTEPARTAL PERIOD: DURATION

o Days: 267 – 280

o Months: 9
o Weeks: 37 – 42
o Lunar Month: 10 months
• Age of Productivity: 15 – 44
• High Risk Pregnancy: Less than 18, More than 35
• Ideal age for Pregnancy: 20 – 30 years old
• Menopausal Baby: 44 years old and above
• Prenatal visits for Uncomplicated Pregnancies → There must be 4 visits (at least)
o 1st Trimester = 1 (before 4 months)
o 2nd Trimester = 1 (6th month)
o 3rd Trimester = 2 (8th and 9th month)
▪ NOTE: No Home-Birthing Policy implemented in 2008
▪ G1 and G5 and above = Hospital
Based on DOH
▪ G2, G3 and G4 = lying-in and hospital
▪ Grandmultigravida = 5 or more pregnancies

ESTEMATING THE EEXPECTED DATE OF BIRTH

• MOST POPULAR RULE = NAEGELE’S RULE

o # LMP → First day of Last Menstrual Period
▪ If LMP is January to March = + 9 months + 7 days + same year
▪ If LMP is from April to December = -3 months + 7 days + 1 year

ESTIMATION OF AGE OF GESTATION

• Bartholomew’s Rule
o Starts on 3rd month = cannot palpate fundus earlier than 3 months
o Rule of 4
o Void before the procedure
o Position of the Woman: Dorsal Recumbent with Knee slightly bent to relax the abdomen → easier to palpate fundus
▪ 42 weeks = 2 fingers below the Xiphoid Process due to lightening
▪ At the level of umbilicus = 20 – 22 weeks
• Fundic Height in Centimeters
o 20 – 36 cm = 20 – 36 weeks of pregnancy
▪ Need tape measure
▪ Need to void, full bladder adds 3 cm
o Affecting Factors:
▪ Volume of Amniotic Fluid
▪ Multiple pregnancy
▪ Obese mother Ultrasound to check AOG
▪ Diabetic Mother
▪ NOTE: Bilateral diameter of fetal head is 8.5 cm and above the fetus is mature

WEIGHT GAIN FOR SINGLETON PREGNANCY

NON-PREGNANT WEIGHT WEIGHT GAIN DURING PREGNANCY

Average (BMI 18.5 – 24.4) 25 – 35 lbs.
Underweight (BMI less than 18.5) 28 – 40 lbs
Overweight (BMI 25.0 – 29.9) 15 – 25 lbs
Obese (BMI more than 29.9) Less than 15 lbs

DISTRIBUTION OD WEIGHT GAIN FOR SINGLETON PREGNANCY

• First Trimester → 1lb/month (first 12 weeks)

• Second Trimester → 1lb/week
• Third Trimester → 1 lb/week
THE AVERAGE MATERNAL WEIGHT GAIN IS DISTRIBUTED AS FOLLOW:

• 11 lbs → Fetus, Placenta, Amniotic Fluid

• 2 lbs → Uterus
• 4 lbs → Increase blood volume
• 3 lbs → Breast Tissues
• 5 – 10 lbs → Maternal Stores
• NOTE: After delivery there is Immediate Weight Loss

CALORIES PER DAY FOR NON-PREGNANT

• 2200/day

CALORIES PER DAY DURING PREGNANCY

• 1st Trimester → 2200/day (No increase yet)

• 2nd Trimester → + 300/day
2,500/ day (+300 for baby)
• 3rd Trimester → + 300/day

CALORIES DURING LACTATION

• + 500 calorie/day = 2700/day

o + 500 per baby
o Don’t increase calories if not breastfeeding
o NOTES:
▪ 1st – 5th month → Maternal Stores
▪ 6th – 10th month → Fetal Stores Lunar Month
▪ The more you carry (multiple pregnancy) the earlier the delivery = at risk for prematurity

SIGNS OF PREGNANCY

• PRESUMPTIVE SIGNS = Subjective (least indicative = cannot be documented)

o Morning Sickness → High HCG/Estrogen
o Fatigue → Increase in Metabolic requirements
o Amenorrhea → (secondary) only documented
o Increase Urinary Frequency → pressure of enlarge uterus to kidney
o Breast Changes → starting 6 weeks
o Quickening/Fluttering Sensation
o Chloasma → dark spots
Increase MSH (starting at 5th month and above)
o Linea Nigra → dark line
o Striae Gravidarum → due to increase estrogen (it will lighten but not totally disappear)
o Uterine Enlargement → felt only by mother
• PROBABLE SIGNS = Objective (more indicative = can be documented)
o Elevated Basal Body Temperature → due to Increase Progesterone
o Ballottement → Fetal Rebound (Floating) → starting 4 – 5 months (multi)
o Braxton Hick’s Contraction → painless, irregular, false labor contractions.
▪ First contraction: Quickening
▪ False labor
▪ Irregular Contractions
▪ Painless→ intense/stronger during 3rd trimester, pulling/tightening sensation with pubic bone
▪ It increases uteroplacental sufficiency (increase blood supply)
▪ Starts at 3rd month and stronger at 3rd trimester
▪ Management to relieved is to WALK
o Chadwick’s Sign → Bluish discoloration of vagina
o Goodell’s Sign → Softening of the Cervix Increase Estrogen, starting 6 weeks
o Hegar’s Sign → Softening of the Lower Uterine Segment
o HCG Test
o Abdominal Enlargement
• POSITIVE SIGN = Undeniable (Confirmatory)
o Fetal Heart Tone
o Fetal Movement felt by the examiner
o Visualization of the fetus via Ultrasound
▪ If Cephalic, the point of maximum impulses (PMI) = below the umbilicus → Occiput
▪ If Breech, above the umbilicus → Sacrum
 If Transverse, near the umbilicus → Acromion (shoulder)
▪
Ultrasounds
▪
• Transabdominal = Full Bladder
• Transvaginal = Empty Bladder
• COUVADE SYNDROME → sign of pregnancy felt by the husband

MATERNAL ADAPTATIONS OF PREGNANCY

CARDIOVASCULAR SYSTEM

• Increased blood volume → starting last week of 1st Trimester

• Increased heart rate → +10 – 15 bpm NORMAL FHR = 110 – 160
• Increase in cardiac output by 30% – 50%
• Blood Pressure may drop slightly in the 2nd Trimester
o Peripheral resistance to circulation is lowered
o BP during Pregnancy
▪ 1st and 3rd Trimester: Pre-pregnancy BP
▪ 2nd Trimester: Slightly lowered
o Increase BP during Pregnancy = Abnormal
▪ More than 20 weeks = Hydatidiform Mole
▪ Less than 20 weeks = PIH
o Hypertension before pregnancy = Chronic Hypertension
• Classification of Cardiac Disease
o Class 1 = No Limitations → Yes to pregnancy and Push
o Class 2 = Slight Limitations → Yes to pregnancy, no to push = CS
o Class 3 = Moderate Limitations → No to pregnancy – light activity, high risk
o Class 4 = Marked Limitations → No to pregnancy
• Increase in Plasma Volume 50%
• Increase in RBC volume by 20% – 30%
• The normal hematocrit in the non-pregnant woman is 38% – 47%
• Normal Value in Pregnancy
o Hematocrit → 32% – 42%
o Hemoglobin → 10.5 – 14 g/dL
• Physiologic Anemia of Pregnancy = 2nd Trimester AKA False/Pseudo/Dilutional
o Increase Iron 30 mg/day → to increase RBC formation
o Twin pregnancy → 60 – 100 mg/day
o Increase Vitamin C → 80 – 100 mg/day = helps absorb iron better
o PICA → eating non-food items (unknown cause). It will decrease iron absorption
▪ After delivery of twins, mother needs to take iron
o Supine Hypotension Syndrome → 2nd to 3rd Trimester
o Edema on the lower extremities/ankle edema/pedal
o Leg Varicosities → use panty hose and pressure stocking 3rd Trimester Because of the enlarged uterus
o Vulval Varicosities

RESPIRATORY SYSTEM

• The mother needs thoracic breather

• The lungs adjust to provide increased amount of oxygen
• RR increase (16 – 22 cpm)
• Total oxygen consumption increases by 20%
o To meet fetal needs
▪ Increase Tidal Volume
▪ Increase Inspiratory Capacity
▪ Decrease Partial CO2
▪ Decrease Expiratory Capacity
▪ ABG: Respiratory Alkalosis Fully Compensated
• The lungs expand laterally
• Diaphragm is displaced upward
• Hyperventilation
• Shortness of breath occur
• Nasal Congestion → due to increase Estrogen
o Hearing Difficulty (early in pregnancy)
SKIN

• All skin changes during pregnancy are presumptive sign (pigment changes)
• Phlegmasia Alba Dolens is most often seen during second half of pregnancy (milk/white leg)
• Striae Gravidarum

GIT SYSTEM

• A hypotonic gastrointestinal tract

Due to High Progesterone or Relaxin
• The smooth muscle of stomach and intestine relax
• The stomach compresses upward and backward (Decrease HCl production)
• Delayed Emptying (3 – 4 hours)
• Food Cravings
• Softening of the Gums → Due to High Estrogen
• Morning Sickness → Due to High Estrogen and HCG
• Heartburn/Pyrosis → reflux (No highly acidic food) = Due to High Progesterone
• Flatulence → Excessive Gas (No Gas Forming Foods) = Due to High Estrogen
Due to High
• Constipation → Due to High Progesterone (No Laxatives and Enema, Yes to Mild Stool Softeners) Progesterone
• Hemorrhoids → Due to pressure of enlarged uterus (3rd Trimester/After Delivery)
o All sweets are highly acidic, gas forming
o Baguio products and root crops are gas forming foods
o No Straining, Valsalva Maneuver, Constipation, Spicy, and Hot Compress
o Patient can do Sitz Bath, Cold Compress, and Push Gently

URINARY SYSTEM

• Kidneys increase renal plasma flow by 30% – 50%

• Kidney increases in size
• Increase urination (1st and 3rd Trimester)
• Increased bladder capacity (2nd Trimester)
• Decrease Glucose threshold = +1 Glycosuria = Pregnancy (Normal)
• During Pregnancy → Increase Progesterone → Decrease Bladder Tone → Urine Stasis (Retention) → At risk for UTI → Ask the
mother for burning sensation upon urination (ascending infection)

MUSKULOSKLETAL SYSTEM

• Flexible ligaments and joints of the pelvis → Due to High Progesterone and Relaxin
• Waddling Gait → late in pregnancy
• The enlarging uterus may cause DIASTASIS RECTI, the separation of the rectus muscles of the abdominal wall
• Leg Cramps → Due to imbalance; Decrease Calcium and Increase Phosphorus
o Management:
▪ Increase Calcium → 1200 mg/day
▪ Increase Vitamin D → 400 – 800 IV/day (helps absorb calcium better)
▪ Dorsiflexion → provide immediate relief
▪ NOTE: Calcium is greater than 2500/day may lead to Renal Calculi (Kidney Stones)
• Lordosis → “Liyad”
o To maintain balance
o 3rd Trimester
o Pride of Pregnancy
o Disadvantage: Low Back Pain
▪ Management:
• Pelvic Rocking/Tilt
• Firm Mattress

REPRODUCTION SYSTEM

• The Uterus increase in 20 times in its original size

• The cervix is softening, more vascular Due to High level of
• Mucus plugs seal the cervix Estrogen
• Increase whitish vaginal discharge
• Vaginal secretions become more acidic (pH Level: 3 – 4), it prevents bacterial invasion
o Non-Pregnant pH Level: 4 – 6
o Candida Albicans → could thrive in an (fungal infection) acidic environment
 • Chadwick’s Sign
• Hegar’s Sign
• Breast Changes (starting at 6 weeks)
• Egg Production stops in the ovaries

During Pregnancy
Increase Estrogen → No FSH → No Maturation of Ovum
Placenta No Menstruation
Increase Progesterone → No FSH → No Ovulation

o Tailor Sitting
o Squatting To stretch Perineal Muscle
o Kegel’s Exercise

PREGNANCY INDUCED HYPERTENSION (PIH)

• Cause: Unknown/vasoconstriction of unknown etiology

• When: After 20 weeks (2nd Trimester)
• Former Name: Toxemia
• Types:
o Gestational Hypertension → Hypertension after 20 weeks only
o Pre-Eclampsia
▪ P – Proteinuria
▪ R – Rising BP
▪ E – Edema
o Eclampsia → Maternal mortality is high
▪ + Convulsion (Tonic (20 secs, Stiffening) – Clonic (1 minute, Jerking)) Seizure
• Management:
o Safety
o Airway
• Major Body Part Affected
o B – Brain (CNS Irritation and Hyperreflexia)
o U – Uterus (Uteroplacental Insufficiency)
Due to Vasoconstriction
o L – Liver and Pancreas (Ischemia)
o K – Kidneys (Oliguria and Proteinuria)

MILD PRE-ECLAMPSIA SEVERE PRE-ECLAMPSIA

Blood Pressure +30 Systolic, +50 Diastolic +50 Systolic, +30 Diastolic
140/90 160/110
Proteinuria +1 and + 2 +3 and +4
3 g/L in 24 hours 5 g/L in 24 hours
Edema Digital Periorbital
Upper Extremities Surrounding Eyes/Generalized Edema
Weight Gain 2 lbs per week 5 lbs per week
(Early Sign)
Urine Output More Than 500 cc in 24 hours Less than 500 cc in 24 hours
Headache Occasional Persistent
Visual Disturbance None Present
Epigastric Pain None Aura for Confusion
(Late Sign)

• NOTES:
o BP is taken twice, 6 hours apart, right arm
o Blurring Vision or Visual Disturbance → Report because it is a DANGER SIGN
• Complications:
o HEELP Syndrome → Hematologic and Hepatic Problem
▪ H – Hemolysis
▪ E – Elevated
▪ E – Liver Enzymes → AST and ALT (Liver Function Test)
▪ L – Low
Thrombocytopenia
▪ P – Platelet Count
 ▪ Management:
• Delivery of the Baby ASAP to prevent stillbirth
o Pregnancy-Induced Hypertension (PIH)
▪ Home Management is Allowed if the woman meets the following:
• Blood pressure less than 150/100
• Proteinuria less than 1g/24 hours Should be all meet
• Normal Platelet Count = 150,000 – 450,000 by the mother
• No Fetal Growth Restrictions
• Hospital Care for Mild Pre-Eclampsia S
o The woman is placed in bed rest
▪ Position: Left Lateral Recumbent → to increase venous return
▪ Diet: Increase Protein (70 – 80 g/day)
▪ Room: Dim and Quiet (Non-stimulating to prevent seizure)
o Antihypertension
▪ Hydralazine (Apresoline), Aldomet (Methyldopa), Normodyne (Labetalol), and Nifedipine (Procardia)
▪ Given to severe Pre-Eclampsia
▪ Therapeutic Goal: Decrease BP slightly than 140/90
o Anticonvulsant
▪ Magnesium Sulfate → CNS Depression/Muscle Relaxant
▪ Route: IV/IM (2 track) Gluteal Muscle DO NOT MASSAGE
▪ Therapeutic Level: 4 – 7 / 5 – 8 Meq/L
▪ Check RR first, if less than 12 don’t give
▪ Check 2nd the Patellar Reflex
▪ Monitor ANKLE CLONUS every hour → Normal: Absent
• Ankle Clonus = continued motion of the foot
▪ Monitor PATELLAR REFLEX every hour → Normal: Present
• Average Response: +2
• Abnormal: +4 and +0
o +4 → Hyperactive (Abnormal)
o +3 → Brisker than average
o +2 → Average (Normal)
o +1 → Diminishing
o +0 → No Response (Abnormal)
o Evaluate Magnesium Toxicity
▪ BP: Low/Hypotension
▪ Urine Output: Decrease (Less than 30cc/hr)
▪ RR: Decrease (Less than 12 cpm)
▪ Patellar Reflex: Absent (1st sign of Magnesium Toxicity)
▪ Somnolence: Strong desire to sleep
▪ Antidote: Calcium Gluconate
• 9 – 12 mEq/L → Toxicity, Absent Patellar Reflex
• 15 – 17 mEq/L → Respiratory Depression
• 30+ and above → Cardiac Arrest
o Management for Seizure: Priorities
1. During Seizure: Safety
2. After Seizure: Maintain Airway
a. Side rails up
b. Position the woman on her side → to prevent aspiration
c. The airway should be observed for onset of labor
d. Monitor FHR
e. The woman is monitored for signs of Abruptio Placenta
i. Sign: Board-like Abdomen
f. Check the woman every 15 minutes for Vaginal Bleeding
o Intrapartal Management:
▪ REAL CURE: Birth is the only known cure for hypertension
▪ Labor may be induced by intravenous oxytocin when there is evidence of fetal maturity (37 weeks and above) and
cervical readiness (buttersoft)
• Oxytocin: Piggyback
• Goal: 60 seconds Duration of Contraction
• Oxytocin has ADH Effects
▪ In severe cases, CS may be necessary
 ▪ Oxygen administration via face mask
o Postpartum Management:
▪ Monitor the patient for 48 hours after delivery
▪ A woman will continue to receive the infusion of Magnesium Sulfate for about 24 hours post-partum (convulsion
may occur)
o Diabetes Management During Pregnancy
▪ Instruct to a woman with established diabetes
▪ Pre-conception and early-pregnancy
• At pregnancy, advice should be given about good diabetic control, diet, smoking, and folate supplement
with frequency visits planned as required.
o Maintain a normal blood glucose 1 – 2 months prior pregnancy
o Hyperglycemia = 1st Trimester may lead to Congenital Malformation and Abortion

MATERNAL RISK

• Polyhydramnios may result in Prematurity

• Pre-eclampsia
• Dystocia particularly shoulder
• Maternal infections particularly in the Urinary Tract
o Diabetic Mother: NSD (Delivery) → High Risk for Infection

FETAL RISK

• Congenital Anomalies (most common: Heart Anomaly)

• LGA/Macrosomia: Greater than 4000 g Birth Weight
• Increased Risk for Birth Trauma → broken clavicle
• Increased Incidence of RDS → Delayed Lung Maturity (38 weeks)
• Hypoglycemia: With 1 hour after delivery
o To the newborn
o Management: Breast feeding the baby ASAP

Excessive Glucose Hyper insulin Delayed Surfactant

transport to Fetus production of Fetus Production

• The first therapy for GDM is DIET!

• If DIET is inadequate → Insulin
• Oral Hypoglycemic are never use during pregnancy

INSULIN REQUIREMENTS DURING PREGNANCY

• 1st Trimester → Decreased (Decrease Maternal Intake)

• 2nd Trimester → Increased (Increase Placental Hormone)
• 3rd Trimester → Increased (Increase Placental Hormone)
• Labor and Delivery → Decreased (Increase Metabolism)
• Immediate post-partum → rapid return (Due to loss of placenta) to pre-pregnancy levels
• Breast Feeding → Decreased → Carbohydrates is used for milk production

TIMING OF BIRTH

• Woman with good control of their diabetes and no sign of complication are allowed to continue pregnancy until term
• Fetal lung maturity is delayed (38 weeks)
• Assessment of Surfactant levels is recommended to help determine delivery time
o L/S Ratio should be 3:1 or 2:5:1
o Presence of Phosphatidyl Glycerol (PG)
• Post-partum Consideration:
o The woman with GDM should maintain a normal weight after delivery to reduce the risk for Type 2 Diabetes Mellitus in later
years.

BLEEDING DISORDERS OF PERGNANCY

• Abortion
o Spontaneous/Miscarriage
o Induced:
▪ Intentional
 ▪ Therapeutic
• Methods of Abortion
o Medical Termination avoids a General Anesthesia
o Medical Termination may be more effective at earlier gestation
▪ Oral administration of Mifepristone, an anti-progesterone ,and
▪ Prostaglandin or Misoprostol Pessary
• Surgical Termination
o Misoprostol Pessaries are given 4 hours prior to operation to soften the cervix to minimize trauma from the dilation.
o Evacuation of the Uterus: Under General Anesthesia
o Rigid or Flexible suction curettage is used to aspirate fetus and placenta
• Type of Abortion:
o Threatened
▪ Cervix is closed
▪ Possible loss, mild bleeding, non-tender uterus (painless)
▪ Management:
• No sex for 2 weeks
• No lifting heavy objects
• Bed Rest until bleeding subsides
• Observe for increasing blood loss
o Inevitable
▪ Cervix – Dilated
▪ Imminent, loss cannot be prevented, moderate bleeding, mild to painful uterine contractions, membranes may
rupture. No passage of abortus yet.
o Incomplete
▪ Cervix – Dilated
▪ Some products are expelled, severe bleeding due to retained placenta
▪ Most painful type of abortion
▪ Completion Curettage (Management)
▪ Possible for Uterine Infection
o Complete
▪ Cervix – Closed/Open
▪ All products are expelled from the uterus
o Habitual
▪ Most common cause: Incompetent Cervix
▪ Recurrent (3 or more consecutive pregnancies have ended in spontaneous abortion)
o Septic
▪ As complication of incomplete abortion
▪ Abortion complication by infection (foul smelling vaginal discharge)
o Missed
▪ Cervix – Closed
▪ Retention (dead fetus syndrome), the fetus died before 20 weeks but retained for 4 weeks or more
▪ Sign of pregnancy disappear HCG is negative (-)
▪ At risk for Disseminated Intravascular Coagulopathy

ANEMBRYONIC PREGNANCY

• Embryonic development fails at a very early stage in the pregnancy, the sac continues to develop, but there is no fetal parts evident
on ultrasound scan.
• Former Term: Blighted Ovum

ECTOPIC PREGNANCY OR TUBAL PREGNANCY

• Any Blastocyst implantation outside the uterus

o Most common Site: Ampulla of the Fallopian Tube
▪ Duration of Ectopic: 6 – 12 weeks
o Second most common site: Isthmus (Narrowest)
▪ Duration: 6 – 8 weeks
 • Risk Factors:
o Previous Pelvic Inflammatory Disease (PID)
▪ Cause of PID:
• Chlamydia
• Gonorrhea
• Post-partum endometritis
• Postpartal Uterine Infections Fallopian Tube Scar Formation
o Previous Ectopic Pregnancy, Previous BTL, Previous Tubal or Pelvic Surgeries
o Maternal Smoking at the time of Conception
• Signs and Symptoms Narrowing
o Before Rupture (Risk for Ectopic Pregnancy)
▪ Classical Symptoms
• Lower and Unilateral abdominal pain, delayed menses, abnormal vaginal bleeding (dark red/brown)
→ 6 – 8 weeks
• Low HCG, low estrogen, and low progesterone

Decrease Progesterone
Wrong site for Decrease Nutrient
implantation Supply Low HCG production Corpus Luteum
Decrease Estrogen

Bleeding Cannot maintain endometrium

o After Tubal Rupture

▪ Deep, generalized, unilateral, acute lower quadrant pain
▪ Bleeding in the pelvic cavity
▪ Cullen’s Sign → Bluish Navel/Hematoperitoneum
• Indicative of Internal Bleeding
▪ Kehr’s Sign → Referred Pain
• Pain radiating to neck and right shoulder due to stimulation of phrenic nerve (Diaphragmatic Nerve)
o Management:
▪ Non-Surgical Treatment → Methotrexate (IM, Folic-acid Antagonist)
• Pre-requisite:
o Ectopic sac is smaller than 3.5 cm in diameter, serum HCG levels less than 5000 mIU/mL,
Liver Function Test within normal levels, normal kidney function, no evidence of
Thrombocytopenia
▪ Surgical Treatment for Unruptured Tubal Pregnancy
• Salpingostomy
▪ Surgical Treatment for Ruptured Tubal Pregnancy
• Salpingectomy

HYDATIDIFORM MOLE / MOLAR PREGNANCY

• Gestational Thromboplastic Disease

• The Chorionic Villi develop into edematous, cystic avascular transparent vesicles that hang in a grape-like cluster
• Cause: Unknown
• Signs and Symptoms:
o Uterus is larger than the estimated gestational age
o Snowstorm pattern seen in ultrasound
o No fetal heart tone
o Passage of vesicles → Confirms H. Mole
o Excessive HCG
o Hyperemesis Gravidarum → severe nausea, vomiting, weight loss, and possibly dehydration
o Hypertension before 20 weeks
o Ovarian Enlargement
o When Molar tissues separating from the uterus, bright red bleeding may result
• Types of H. Mole
o Partial H. Mole
▪ One set of chromosomes of maternal in origin and 2 sets of paternal in origin → 69 Chromosomes (Triploid)
o Complete H. Mole
 ▪ A sperm fertilizes and ovum with no genetic material.
▪ At risk for Choriocarcinoma
• Duplication of paternal set. 46 Diploid
• Diagnostic Test:
o Transvaginal Ultrasounds and Serum HCG
• Management:
o Remove the moles → suction evacuation or Dilation and Curettage
o Oxytocic after evacuation
o Follow-up visits → check HCG levels monthly for 6 – 12 months
▪ For Complete H. Mole because they are at risk for cancer
▪ Goal: To reduce HCG levels
o Regular Chest X-ray and regular pelvic Examination
▪ To check to metastasis
o DRUG OF CHOICE: For Choriocarcinoma → Methotrexate (If HCG is Increase)
o Other Consideration:
▪ No pregnancy for at least 1 year
▪ Recommended to use contraception
▪ Abdominal Hysterectomy (optional)

INCOMPETENT CERVIX

• Painless premature cervical dilation before 20 weeks

• Due to:
o Congenital Incompetence → short cervix (less than 20 cm)
o Acquired Incompetence → previous cervical trauma
• Signs:
o Bloody shows before 20 weeks
▪ Pinkish discharge (mixture of operculum and blood)
• Best Diagnostic Test: Transvaginal Ultrasound → To detect
• Management:
o Cervical Cerclage → Cervical Suturing (10 – 14 weeks or 12 – 16 weeks)
▪ Types of Cervical Cerclage
• McDonald → The simpler procedure (temporary)
o NSD/NSVD
o Before or prior delivery (removal)
• Shirodkar → The more complicated operation (permanent)
o Automatic CS
o After delivery (removal)
o Success Rate: 85% – 90%, when either technique is performed
o NOTE: following the Shirodkar operation, the sutures maybe left in place, and cesarean
delivery preformed.
o NOTE: Most practitioner reserve the Shirodkar procedure for women with previous failure of
the McDonald Cerclage or those structural cervical abnormalities.
▪ After Cerclage:
• Position: Slight Trendelenburg (to reduce pressure)
• What to Observe: Rupture of Membrane (ROM), contraction, infections
• No sex, no lifting anything heavy, no prolonged sitting and standing (for more than 90 minutes)
3rd TRIMESTER BLEEDING DISORDER

PLACENTA PREVIA ABRUPTIO PLACENTA

(Placenta in the cervical opening) (Early Separation)
Abnormal Implantation Normal
1. Complete Types 1. Covert
2. Partial CS (Classical) Central
3. Marginal Concealed
4. Low-Lying NSD Common
Clor
2. Overt
Edge
Escape
Less common
External Bleeding Only Bleeding Internal or External Bleeding
Bright Red Color Dark-Red or Bright Red
Soft and non-tender Uterus Board-like and tender
(palpable uterus) (rigid and non-palpable uterus)
Painless Pain Painful
Multiparity Common Cause and Other Causes Hypertension
(Fundal Scarring) (Vasoconstriction)
S – Smoking S – Smoking and Short Cord
P – Previous CS + Abortion C – Cocaine use (more than 20 weeks)
A – Advance Age (more than 35 years old) A – Age (more than 35 years old)
M – Multiple Pregnancy M – Multiple Pregnancy